Pundit-Based Medicine

Published on December 16, 2015
Emergency physicians need to pay less attention to what is trending online, and focus more on practicing good, consistent medicine with evidence-based protocols.

We are now generating more scientific publications than ever before—by an order of magnitude. Emergency medicine (EM) sees itself at the forefront of many of the new treatment paradigms, especially in domains such as trauma, stroke, sepsis, cardiology, and geriatrics, where clinical pathways have all changed rapidly over the last decade. We are constantly bombarded by Twitter, Facebook, Whatsapp, new “authoritative” websites, and a myriad of other social media—all so we can “keep up.” Terms such as FOAMed (Free Online Meducation) are promoted to suggest that we might actually be helped by such avenues.

How useful is all this information? If we had neglected the last 10 years of these “scientific advances,” would we have lost any salvageable patients? How do we assess whether any of the constant flow of information is useful? Would it matter if many of the advances were delayed by a few years until adequate assessment of cost and impact were undertaken? Even more importantly, if we had not followed the latest trend, and used our energy to focus instead on standardization of current protocols, would we have had better outcomes?

The evidence-based medicine movement from 20 years ago promoted evidence above eminence. It seems that now our colleagues bypass reading the real evidence and go straight to the latest false prophet—usually in 140 characters.

Just this year, 10 years of sepsis guidelines promoting “Early Goal Directed Therapy” have been thrown out the window. The ARISE, PROCESS, and PROMISE trials showed that good clinical assessment and management was not helped by the arbitrary application of “goals” for resuscitation. The mandatory use of oxygen for critically ill patients has been shown to be potentially harmful in the AVOID trial, despite the constant mantra to use supranormal oxygen therapy. As yet, large RCTs randomizing liberal vs. limited oxygen therapy have not been undertaken. The mandatory use of cervical collars for trauma patients might also be harmful, especially in the elderly. Again, large-scale RCTs showing safety of restricted use of cervical collars are yet to be undertaken. The massive transfusion ratios in trauma of 1:1:1 for blood/FFP/Platelets may kill non-trauma patients, such as those GI hemorrhage, and haven’t stood up in an RCT in trauma. Yet these protocols have been widely promoted because of strong advocacy on the basis of uncontrolled observational studies.

The bottom line is that unless there are multiple RCTs demonstrating a clear advantage, we have to be skeptical of all dogma. Especially dogma that comes in sound bites from random websites and without assessment by academic groups.

Should the average emergency trainee/physician listen to the constant chatter online, or wait for definitive statements from appropriately qualified expert groups? It seems to me that there is more risk from constantly changing protocols according to fashion than using the current evidence-based protocols consistently.

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

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